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Specific Management of PPH
Published in Gowri Dorairajan, Management of Normal and High Risk Labour During Childbirth, 2022
Case: This case is before the B-lynch suture became the standard protocol. A woman was admitted at 34 weeks with severe preeclampsia, abruption, and intrauterine death. Labour was induced, and the women delivered a stillborn fetus. There were significant retroplacental clots. A massive atonic postpartum haemorrhage followed the delivery. The uterus did not respond to pharmacological agents, so surgical intervention was carried out. Systematic devascularisation was done, and in a desperate attempt to save the uterus, a figure of 8 compression suture was applied in the upper segment of the myometrium and was tied tightly. The suture controlled the bleeding. The patient successfully recovered after intensive support and massive blood and component transfusion. One year later, she presented at 24 weeks of pregnancy in haemorrhagic shock with intrauterine death and hemoperitoneum. Urgent laparotomy was performed. At laparotomy, there was a 1-L hemoperitoneum. The upper segment of the uterus had ruptured in a Z shape at the site of the previous compression suture. A hysterectomy was performed.
Uterine Compression Sutures
Published in Sanjeewa Padumadasa, Malik Goonewardene, Obstetric Emergencies, 2021
The B-Lynch suture was originally described for the management of uterine atony refractory to medical treatment at caesarean delivery, and therefore, the uterine cavity should already be open for it to be applied. After its application, it resembles the braces which are used to hold up the trousers of a man, hence it is also referred to as ‘Brace Sutures’. A No.1 absorbable suture of sufficient length (at least 90 cm) is passed back and forth over the anterior and posterior surfaces of the uterus using a large (>70 mm) round-bodied needle while the assistant maintains compression of the uterus (Figure 17.1). If a large round-bodied needle is unavailable, then an 8–10 cm long straight needle can be used as an alternative. While the assistant manually compresses the uterus incrementally, the suture is progressively tightened. Once adequate compression and tightening are achieved, the two ends of the suture are tied together. The uterine incision is then closed in the routine fashion.
Surgical considerations including haemorrhage and transfusion
Published in Sheila Broderick, Ruth Cochrane, Trauma and Birth, 2020
Sheila Broderick, Ruth Cochrane
The brace suture or B-Lynch suture is a surgical technique that stops haemorrhage from an atonic uterus by causing mechanical compression. It is essentially a stitch version of bimanual compression. It was originally described in 1997 after experience of five successful cases (B-Lynch 1997). Since then the suture has been used worldwide, with the advantages of being relatively simple to perform and allowing the woman to preserve her uterus for a possible future pregnancy. Many women have become pregnant following a brace suture and studies have shown them to have no adverse pregnancy outcomes (Cowan et al 2014).
Catastrophic uterine rupture associated with placenta accreta after previous B-Lynch sutures
Published in Journal of Obstetrics and Gynaecology, 2018
F. H. Harlow, R. P. Smith, J. Nortje, B. O. Anigbogu, X. Tyler
A 31-year-old woman presented in her second pregnancy. Five years earlier, she had a caesarean section through a transverse lower uterine segment incision. The uterine incision did not tear and it was not extended as an ‘inverted T’ or ‘J’. She had a massive blood loss due to uterine atony, which did not respond to utero-tonics. A B-Lynch suture was inserted using 2/0 poliglecaprone 25. The bleeding continued and a second B-Lynch suture parallel to the first one was inserted, achieving haemostasis. She was advised that there was no contraindication to vaginal birth in future pregnancies. There was no additional history of uterine surgery. In this pregnancy, she went into spontaneous labour at home at 39 weeks’ gestation. An ambulance was called due to her severe, constant abdominal pain, which made it impossible for her to be brought in by car. She had a cardiac arrest in the ambulance and on arrival at hospital (12 minutes later) had a peri-mortem caesarean section.
A case report of complications following a combination of modulated B-lynch and Hwu sutures in postpartum haemorrhage: haematocele in the uterine cavity, hemoperitoneum and swelling and rupture of the fallopian tube
Published in Journal of Obstetrics and Gynaecology, 2019
There is no doubt that B-Lynch sutures have been successful in preserving the uterus and reducing maternal mortality in women who experience massive PPH. However, it has some shortcomings and is associated with severe long-term and short-term complications. For example, in one case report (Joshi and Shrivastava 2004), partial ischaemic necrosis of the uterine wall was observed 24 h after the operation. A long-term complication, myometrial necrosis, occurred in a subsequent pregnancy because one B-Lynch suture and two Cho suture procedures were performed to treat PPH in her first caesarean. Uterine ruptures have been documented in the second trimester of a second pregnancy, which occurred after four months of amenorrhoea (Pechtor et al. 2010) and during the third trimester of a pregnancy, after 32 weeks of gestation (Date et al. 2014). Many previous reports of surgeries performed using compressing sutures, such as modified B-Lynch and Cho sutures (Weisbrod et al. 2009), or parallel vertical compression sutures, such as Hwu sutures (Hwu et al. 2005), have demonstrated that these sutures can treat PPH successfully when used alone. In our own clinical practice, we noticed that the uterus remains flabby after a B-Lynch suture is performed, and that in some of the cases in which the bleeding cannot be stopped, the uterus must be removed. Hence, combining the different compressing sutures with a Bakri Balloon Tamponade and ligation of the uterine and iliac arteries increase the success rate in severe PPH preserving the uterus. Based on the present and previous case studies, we suggest that the best hemostasis method, whether it should be used alone or in combination with other methods, remains to be determined . Further specific and detailed studies should therefore be carefully performed.
The effectiveness of the double B-lynch suture as a modification in the treatment of intractable postpartum haemorrhage
Published in Journal of Obstetrics and Gynaecology, 2018
Hanifi Şahin, Oya Soylu Karapınar, Eda Adeviye Şahin, Kenan Dolapçıoğlu, Ali Baloğlu
In cases of intractable haemorrhage due to uterine atony, compression is needed in a wide area. The double B-Lynch suture is a reliable surgical technique in an intractable postpartum haemorrhage, and it preserves fertility. It should be considered before embarking upon any aggressive surgical techniques, such as a hypogastric artery ligation or a hysterectomy.